Changes to the Public Service Health Care Plan, which took effect on July 1, include $75,000 for certain gender affirming procedures not covered by provincial or territorial health-care programs.
Other new benefits include: $300 per year each for a registered dietician, occupational therapist and lactation consultant; $200 per year for batteries for hearing aids; $600 per year for injectable lubricants for joint pain and arthritis; $200 per year for needles and syringes for injectable drugs; $3,000 per year for continuous glucose monitor supplies (for people with type 1 diabetes only); and $700 for five years for other diabetic monitors.
The changes, which were negotiated at the PSHCP Partners Committee — comprised of employers, bargaining agents and pensioner representatives — include improvements that modernize the plan and respond to the needs of a diverse Canadian public sector workforce, according to a press release from the Treasury Board. The plan covers 1.7 million federal public sector employees, retirees and their dependants.
Read: How employers are using data to integrate DEI into their benefits plans
In terms of mental-health services, the changes include an increase in the coverage from $2,000 to $5,000 annually. In addition, the services can now be administered by a variety of providers such as counsellors, psychologists, psychotherapists and social workers.
Changes to paramedical benefits include: for physiotherapy, the member-paid amount — previously between $500 and $1,000 — has been removed to provide continuous coverage for up to $1,500 in claims; and for massage therapy, osteopath, naturopath and podiatrist or chiropodist, coverage has increased for each from $300 annually to $500.
For vision care, the two-year coverage for prescription eyeglasses or contact lenses has increased from $275 to $300. And for laser eye surgery, plan members and their dependants are now covered for a lifetime maximum of $2,000, up from $1,000. The PSHCP’s coverage for smoking cessation drugs has also increased, from a lifetime maximum of $1,000 to $2,000.
Read: Sounding Board: Is it time to update vision care benefits plan design?
There are also substantial changes for the PSHCP’s drug plan. Following a legacy period ending Dec. 31, 2023, the plan will implement mandatory generic drug substitution. During the legacy period, prescribed brand name drugs will still be reimbursed at 80 per cent of their cost for those with existing prescriptions, if processed electronically at a pharmacy using the PSHCP benefit card. New prescriptions will be subject to mandatory generic drug substitution as of July 1, 2023. And as of Jan. 1, 2024, all prescription drugs covered under the PSHCP will be reimbursed at 80 per cent of the cost of the lowest-priced alternative generic drug.
The PSHCP will also implement a prior authorization program, which will take effect on July 1, 2023, for a sub-set of specific prescription drugs that require special handling — for example, biologic drugs that are administered by a medical professional in a clinical setting.
Prior to July 1, 2023, if a member was on any of the prescription drugs that were part of the prior authorization program, they wouldn’t be required to go through the prior authorization process to continue receiving that prescription. However, members may have needed to switch their existing biologic drug to a biosimilar drug. After July 1, 2023, if a member is prescribed a drug that’s on the list, they’ll be required to go through the prior authorization process to have the medication pre-approved for reimbursement under the PSHCP.
Read: Specialty drug prior authorization a useful tool for plan sponsors
Also beginning July 1 and over the following two years, if a plan member is on a biologic drug where there’s a biosimilar available, the plan administrator may contact the member directly with transition details. Exceptions will be considered based on medical evidence.
In addition, eligible drug expenses will be reimbursed at 100 per cent when out-of-pocket drug expenses exceed $3,500 in a calendar year. This is an increase from the previous $3,000 per year. And the PSHCP will reimburse up to a maximum of $8 for the pharmacy dispensing fee. However, the dispensing fee cap won’t apply to biologic or compound drugs.
In addition to all of these changes, the PSHCP has switched its administrator following a competitive procurement process. The plan was previously administered by Sun Life Financial Inc. and it will now be administered by the Canada Life Assurance Co.
In response to complaints of long wait times and other issues with the transition, as reported by CBC and other news outlets earlier this month, a Canada Life spokesperson said: “We’re pleased that more than 90 per cent of plan members have successfully enrolled and, since July 1, we’ve paid close to 1.5 million claims for PSHCP members. Along with several updates and enhancements to the plan offering for members, this transition has come with challenges in ensuring every member enrols.”
Read: Prescription drug costs for Canadian public plans hit $11.4 billion in 2017/18: report
These challenges include high call volumes and longer than usual waits times, according to the spokesperson. “We appreciate plan members’ patience and we apologize for the inconvenience. Over the past few weeks, we’ve been working hard to make things right.”
Canada Life has increased staff in the PSHCP member contact centre and temporarily extended its contact centre hours. As well, with the support of the government, the insurer has introduced steps to accelerate the enrolment process for the remaining plan members. “These actions are helping improve the experience and reduce wait times.”